Active IQ Level 3 Diploma in Exercise Referral (sample manual)

Manual 

Level 3 Diploma in 

Exercise Referral – 

All Units 

Version AIQ005179

Section 1: The heart and circulatory system and its relation to exercise and health 

The valves of the heart 

In order to function effectively as a pump, the heart needs 

to direct blood through the atria, ventricles and then the 

arteries of the body. The heart prevents unwanted backflow 

of blood into the chambers using a number of valves. 

These valves open and close in response to changes in 

pressure as the heart contracts and relaxes. The structure 

of the valves means that they only allow blood to flow 

in one direction by shutting once blood has been pushed 

through them. This is fundamental to effective circulation; 

any back-flow through the heart will compromise the 

efficiency of each heartbeat, which is likely to affect 

exercise performance and health. 

The main valves of the heart are the atrioventricular (AV) 

valves and the semilunar (SL) valves. The AV valves are 

located between the atria and the ventricles and prevent 

the back-flow of blood from the ventricles into the atria. 

As the ventricles contract, pressure rises and forces the AV 

valves to snap shut, allowing blood to be directed through 

the arteries leaving the heart (pulmonary artery and aorta). 

SOMETHING EXTRA 

As the AV valves snap 

shut, they are anchored 

in place by tendonlike 

chords (chordae 

tendineae) which prevent 

the valve flaps from being 

pushed too far into the 

atria. 

The SL valves are located at 

the base of the arteries leaving 

the heart (aorta and pulmonary 

artery). After each contraction, 

there is a relative drop in 

pressure within the ventricles 

as they relax. At this point, the 

blood within the pulmonary 

artery and aorta could potentially 

flow back into the ventricles. To 

prevent this, both sets of arteries 

have SL valves positioned at the 

point where they emerge from the ventricles. As the blood 

moves back towards the ventricles, the SL valves snap 

shut so blood cannot re-enter. 

It is the sequential shutting of the valves during the cardiac 

cycle that causes the distinct ‘lub-dub’ noises associated 

with the heartbeat. 

Superior 

vena 

cava 

Right 

pulmonary 

veins 

Right 

atrium 

Right 

ventricle 

Inferior 

vena cava 

Atrioventricular (AV) 

valves 

Aorta 

Pulmonary 

artery 

Figure 1.2 The heart 

Figure 1.3 The valves of 

the heart 

Left 

pulmonary 

veins 

Left 

atrium 

Left 

ventricle 

Semilunar 

(SL) valves 

MEMORY JOGGER – HEART CIRCULATION 

The heart is stimulated to contract by a complex series of integrated systems. The heart’s pacemaker – 

the sinoatrial (SA) node – initiates the cardiac muscle contraction. The SA node is located in the wall of 

the right atrium. The myocardium (heart muscle) is stimulated to contract about 72 times per minute 

by the SA node as part of the autonomic nervous system. 

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Risks of high blood pressure 

It is normal for blood pressure to temporarily increase during exertion or when feeling anxious or stressed. 

Hypertension (high blood pressure) is the term used to describe blood pressure that is consistently higher 

than the healthy level when at rest. A high SBP provides an indication of the strain on the blood vessels when 

the heart is attempting to pump out blood. If the DBP is high, it indicates that the blood vessels have little 

chance to relax between heartbeats. Consequently, measuring blood pressure provides an indication of the 

health of the vascular system and an overall gauge of a person’s health. 

ACTIVITY 

The term ‘white coat hypertension’ may be used if you have high blood pressure readings 

(i.e. readings that are consistently 140/90mmHg or above) only when you are in a medical 

setting. Why do you think blood pressure readings might be higher in a medical environment? 

SOMETHING EXTRA 

There are currently 

about 12 million 

people in the UK who 

have hypertension 

(blood pressure 

≥140/90mmHg), and 

more than half of those 

are over the age of 

60. Around 5.7 million 

people have undiagnosed 

hypertension. 

(UK Blood Pressure 

Association, 2012) 

Hypertension increases the risk of ischaemic heart disease and cerebrovascular 

disease – two of the three biggest killers in the developed world. Ischaemic heart 

disease covers a variety of heart conditions including valve disease and more 

acute problems such as myocardial infarction (heart attack). Cerebrovascular 

disease includes acute problems such as haemorrhagic and ischaemic strokes 

and chronically degenerative conditions like vascular dementia and Alzheimer’s 

disease. Hypertension also places stress on the small vessels to the retina, which 

can cause blindness, as well as the small vessels of the kidneys, which can lead 

to renal failure. 

The average resting blood pressure is defined by the American College of Sports 

Medicine (2014) as 120/80 mmHg. A blood pressure of 140/90 mmHg is 

considered to be high. Individuals with measures above 140/90 mmHg are 

encouraged to see their doctor before commencing physical activity programmes. 

Readings above 180 systolic and 110 diastolic are a contraindication for exercise. 

People with low blood pressure readings may also require medical referral (see 

table 1.1). 

MAKE A NOTE 

CATEGORY SYSTOLIC (mmHg) DIASTOLIC (mmHg) 

Low < 100 < 60 

Optimal < 120 < 80 

Normal < 130 < 85 

High normal - Pre-hypertension 130-139 85-89 

Stage 1 Hypertension 140-159 90-99 

Stage 2 Hypertension 160-179 100-109 

Stage 3 Hypertension > 180 > 110 

Table 1.1 Blood pressure classifications (ACSM, 2014) 

An ischaemic stroke is the most common form of stroke and is often caused by a thrombosis (an obstruction of a blood vessel leading to 

the brain by a localised blood clot) or an embolism (an obstruction due to an embolus – a detached blood clot – from elsewhere in the 

body). 

An haemorrhagic stroke is an intracranial haemorrhage (bleed) and can be linked to an aneurysm (a localised, blood-filled, balloon-like 

bulge in the wall of a weakened blood vessel). As the aneurysm increases in size, the risk of it rupturing increases. 

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Short-term effects of exercise on blood pressure 

A short-term effect of exercise is a linear increase in systolic blood pressure (SBP) 

with increasing levels of exertion. In contrast, diastolic blood pressure (DBP) may 

decrease slightly during exertion due to vasodilation, or it will remain unchanged. 

Individuals with hypertension may experience a rise in DBP as a result of an 

impaired vasodilatory response. 

Heavy weight training and isometric exercise will significantly increase both 

systolic and diastolic blood pressure. It is important for an individual not to hold 

their breath when performing these exercises to avoid the Valsalva effect. This 

effect is created by the Valsalva manoeuvre, which involves holding the breath 

while straining or a forced exhalation against a closed airway (glottis). This action 

increases pressure within the thoracic cavity and thereby impedes venous return 

of blood to the heart. During the manoeuvre, the mouth and nose are closed while 

the air is ‘pushed’ against the closed airway without breathing out. It’s similar to 

the pressure created when passing a bowel movement. The Valsalva effect can 

drastically increase blood pressure and heighten the risk of a cardiovascular event 

such as a heart attack or stroke. 

Long-term effects of exercise on blood pressure 

Aerobic exercise using large muscle groups in rhythmical activity is very useful for reducing blood pressure 

over time. Durstine and Moore (2003) state that endurance training can elicit an average decrease of 10 

mmHg in both systolic and diastolic blood pressure in mild and moderate hypertensives. 

Anatomy and physiology for exercise and health 

With the exception of circuit weight training, chronic strength or resistive training has not consistently been 

shown to lower resting blood pressure. Resistance training can have many benefits for hypertensives, but it 

is not recommended as a means of decreasing blood pressure on its own. 

Exercise and blood pressure considerations 

Short-term increases in blood pressure result naturally from physical activity. These increases can be 

exaggerated by the Valsalva effect, which causes rapid short-term rises in blood pressure. Consequently, blood 

pressure can be elevated to dangerously high levels during exercise in people with pre-existing hypertension. 

Increased risk of stroke 

during and immediately 

after exercise. 

Exercise is therefore 

associated with 

a number of 

cardiovascular risks 

including: 

Increased risk of heart 

attack (myocardial 

infarction) during and 

immediately after 

exercise. 

TRAINER TIP 

To avoid excessive 

increases in blood 

pressure while 

resistance training (as 

a consequence of the 

Valsalva effect), inhale 

as you’re bringing the 

resistance back to its 

resting position and 

exhale as you’re working 

hardest against the 

resistance. 

For certain clients, the risks associated with exercise need to be weighed up against the benefits before they 

engage in any physical activity – especially if it’s high-intensity. Physical activity can carry risks for people 

with high blood pressure, but for most people, the benefits far outweigh the dangers. 

Copyright © 2017 Active IQ Ltd. Not for resale | 11

Section 3: Postural and core stability 


One of the most pervasive trends in the health and fitness industry 

has been the continual emphasis on training the core of the body. 

The core is considered to be the trunk of the body, the part left over 

when the arms and legs are discounted. 

The core is often misconstrued as being only the abdominals and 

lower back; the abdominals have probably been focused on too much 

in many training programmes around the country. In this section, we 

will be looking into the different muscles and ligaments that help 

to stabilise the spine and support movement around the core. It’s 

important to appreciate the problems that can result when the core 

musculature doesn’t function as it should. Then, to finish, we will 

look into a few aspects of flexibility that can help to restore good 

movement and function around the body. 

MAKE A NOTE 

Core stability can be defined as: 

‘The ability of your trunk 

to support the effort and 

forces from your arms 

and legs, so that muscles 

and joints can perform in 

their safest, strongest and 

most effective positions.’ 

The stabilising ligaments and muscles of the spine 

(Elphinstone and Pook, 1998) 

The spine is supported by ligaments and muscle tissue that help it to move within set parameters. 

The ligaments of the spine 

The ligaments provide a certain amount of passive support and 

prevent unwanted movement of the spine. There are four main 

ligaments running up and down the length of the spine: 

ANTERIOR 

LONGITUDINAL 

LIGAMENT: 

This connects each vertebral body together 

and runs anteriorly along the front of the 

spine preventing excess extension of the 

spine. 

Anterior 

longitudinal 

ligament 


POSTERIOR 

LONGITUDINAL 

LIGAMENT: 

INTERSPINOUS 

LIGAMENTS: 

INTERTRANSVERSE 

LIGAMENTS: 

This runs along the back of the spine, 

underneath the spinous processes, and is 

also connected to the vertebral bodies of 

each segment. It prevents excess flexion of 

the spine. 

These connect each spinous process to the 

one immediately above or below and, together 

with the posterior longitudinal ligament, 

prevent excess flexion of the spine. 

These connect each transverse process to 

the one immediately above or below. These 

ligaments run on both the left and right side of 

the spine and prevent excess lateral flexion. 

Posterior 

longitudinal 

ligament 

Interspinous 

ligament 

Supraspinous 

ligament 

Intertransverse 

ligament 

Figure 3.1 The ligaments of the spine 

These passive structures are much weaker than muscles and can only withstand a small force (4-5 lbs) 

before buckling (Panjabi et al., 1989), which demonstrates that the muscular system is primarily responsible 

for maintaining core stability and posture. 



An active stretch is one where a position is held with no assistance other than using the strength of the 

agonist muscles. An example would be dorsiflexing the ankle and holding it in that position. The tension of 

the agonists in an active stretch helps to relax the muscles being stretched (the antagonists) by reciprocal 

inhibition. Active stretching increases active flexibility and strengthens the agonistic muscles. Active stretches 

are usually quite difficult to hold and maintain for more than ten seconds. 

Dynamic stretching 

Dynamic stretching, as the name implies, involves movement. It tends to be 

used as part of a warm-up and should be based around the exercise that will 

follow it. The movements used should be performed under control (avoiding 

ballistic type movements), progress from mid to end range and start slowly, 

increasing in speed to promote blood flow and elasticity of the tissues. If 

movements are not controlled in speed and range, there is a potential to tear 

tissues. 

Dynamic stretching helps to reduce the risk of injury by warming the muscle 

tissues and mobilising joints using the types of movement that are about to 

follow in the exercise programme. Care should be taken not to use unnecessary 

explosive movements that could strain tissues before they are ready. 

Proprioceptive neuromuscular facilitation (PNF) 

PNF is a way of taking advantage of the underlying neuromuscular feedback loops inherent in muscle tissue. 

The most commonly used form of PNF is based on the contract–relax principle, where a contraction of a 

target muscle stimulates a subsequent relaxation of that muscle (the inverse stretch reflex). 


During PNF, a muscle group is passively stretched then contracted isometrically (typically for 7-15 seconds) 

against resistance while in the stretched position. After two to three seconds, the muscle is then passively 

stretched again through the resulting increased range of motion. PNF stretching usually employs the use of 

a partner to provide resistance against the isometric contraction and then later to passively take the joint 

through its increased range of motion. PNF may be performed without a partner, although it is usually more 

effective with assistance. 

PNF should only be applied to thoroughly warm muscles and by an experienced practitioner. 


Section 2: ditibe riorection porunt, simo offic to minIpsam 

Section 3: Understanding the healthcare systems in the UK 

fugia aut latiuntio. Fici ommos eatiandest qui doluptium 

The structure of the healthcare systems 

As a consequence of the Health and Social Care Act (2012) the responsibility to deliver Public Health 

moved from the NHS back to the Local Authorities (from where it had originated) on 1st April 2013. This 

brought about changes to the structure of healthcare and also changes to how funding is distributed; GPs 

will hold the majority of the NHS budget, with other allocations going to the Clinical Commissioning Groups 

(CCGs) and Public Health in the Local Authorities. 

Figure 3 illustrates the structure of the healthcare system (2013). Clients and communities are at the centre 

or ‘heart’ of the new model, with layers of other services and bodies, informing the care they receive. 

• People & Communities (the service users) are at the centre (heart) of the model. 

• Local health and care services are the inner layer; and include services that may be visited on a daily 

basis, e.g. pharmacies, GP surgeries, hospitals, opticians. 

• Health and Wellbeing boards (H&WB) oversee all local services. They contain representatives from the 

local services to work together to improve the health of the local community that they serve. 

• Local authorities and Clinical Commissioning Groups (CCGs), form the next layer of the system, their 

role is to ensure services meet community health needs. 

• National organisations including Public Health England and NHS Commissioning boards. 

• Regulation and safeguarding organisations, e.g. Care Quality Commission (CQC) and various 

authorities. 

• Department of Health, Parliament and Government departments form the outer layer. 

Figure 3 The structure of the healthcare system (2013) 

Source: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx 


The use of risk stratification tools 

In the UK most exercise referral schemes have developed their own risk stratification tools and protocols for 

working with specific individuals and groups. In most instances these tools have been developed by working 

collaboratively with local medical practitioners (GPs, physiotherapists etc). To date there has been no single 

model used and this has raised concerns in recent years because it was believed that a standardised approach 

should be adopted across schemes; for both safety standards and monitoring and evaluation purposes. 

Some of the current risk stratification models are introduced next. 

PAR-Q and PARmedX 

The screening tools used by many schemes are the Physical Activity Readiness Questionnaire (PAR-Q) and the 

Physical Activity Readiness Medical Examination (PARmed-X); the latter consists of a physical activity specific 

checklist, developed for physicians to use with clients who have had positive responses (answered ‘yes’) to 

the PAR-Q. The information collected from these tools will usually be listed on a transfer of information record. 

Both questionnaires are designed by the Canadian Society for Exercise Physiology (2002). (NB: These 

documents are under review). 

The risk stratification pyramid 

The risk stratification pyramid (figure 8) presented in the National Quality Assurance Framework for Exercise 

Referral report (NQAF, 2001) provided one of the earliest UK models for risk stratification. The model used 

guidance from the ACSM and identified four levels of client, with apparently healthy populations at the bottom 

of a pyramid, followed by low-risk populations, moderate-risk populations and high-risk populations. At each 

stage of the pyramid the qualifications that an instructor needed prior to working with these groups were stated 

(based on the qualifications available at that time) and the type of exercise environment/activity setting was 

also listed. 

HIGH RISK 

Clinical exercise 

Specialist sessions 

Moderate/Medium risk 

Advanced Instructor (2) 

Referral scheme 

Low risk 

Advanced Instructor (1) 

Referral scheme 

Apparently healthy 

Level 2 instructor 

General exercise programmes 

Figure 8 Risk Stratification Pyramid 

Logic model for risk stratification 

The logic model for risk stratification (ACSM, 2010) suggests that the health and medical history of the person 

should be reviewed to check for the presence of: 

• Known CVD conditions (diagnosis). 

• Signs and symptoms to indicate the presence of cardiovascular disease, pulmonary disease and/or 

metabolic disease. 

• CVD risk factors. 

This model has been perhaps the most commonly used model by most exercise referral instructors (see figure 

9). Individuals who present with more than two signs and symptoms (as per PAR-Q) are signposted to a GP 

prior to participation and may then be referred for a more specialist programme, depending on other factors 

(current activity levels and overall health status).

Active IQ Level 3 Diploma in Exercise Referral (sample manual)

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